The Civil War's surplus of amputations, gunshot wounds, and mental breakdowns
gave America's newly professionalizing neurologists plenty of patients and
opportunity to investigate the intricacies of the nervous system. These neurologists
looked to European scientists, such as Germany's Hermann von Helmholtz, who
stressed the importance of biological energy produced by digestion and presumably
distributed throughout the body by the nervous system.1 Like
the rest of the American medical community, neurologists struggled to find
employment in a postwar health care market flooded by decommissioned physicians.
By 1870, they once again found their services in demand by a growing group
of people seeking medical care: seemingly healthy men and women, usually living
in cities, who experienced physical pain, emotional distress, and profound
exhaustion. To explain this condition, leading neurologists George Beard of
New York and S. Weir Mitchell of Philadelphia combined the European science
of nervous energy with a conservative suspicion of the social changes taking
place in late-century America. The result was neurasthenia, a culturally oriented
diagnosis that attributed mental and physical symptoms to the lack of nervous
energy brought on by the stresses of modern society. Today, the illness stands
as a reminder of the interaction between medicine and culture and helps illustrate
how health care both influences and is influenced by developments in the rest
of society.

The emphasis in neurasthenia on nervous energy makes for a vague disease
by today's standards, but it allowed physicians and patients in the late 19th
century important leeway in tailoring the disease to fit patients' sensibilities
as well as debilities. In so doing, the disease played a role in shedding
professional medicine's "heroic" reputation for leeches and cathartics and
helped recast physicians as scientists and humanitarians.2 In
an article first published in 18693 and
later elaborated on in the seminal work American Nervousness,4 Beard argued that neurasthenia
occurred when people drained their bodies of nervous energy, thereby causing
organs to malfunction and allowing any number of symptoms to arise, including
indigestion, fatigue, muscle and back pain, impotence, infertility, depression,
and irrationality. The exact cause of this drain of energy was not entirely
clear. According to Mitchell,5 two sorts
of persons were particularly at risk of overtaxing their supply of nervous
energy: ultracompetitive businessmen and socially active women. Mitchell thought
both of these groups were unique but unfortunate products of a modernizing
America.

Mitchell was not alone in noticing his nation's dramatic transformation
into a modern society during the decades following the Civil War. Families
migrated from the countryside to the city, men left traditional jobs as tradesmen
and farmers to join the growing ranks of businessmen and office workers, women
went from being mothers and daughters to also being university students and
physicians, and technological developments such as telegraphs, telephones,
and railroads became increasingly common parts of everyday life.6 As
a diagnosis, neurasthenia commanded an intuitive legitimacy because it incorporated
the anxieties that arose from these changes into the way people thought of
their health. It could attribute a bank manager's headaches to his hectic
schedule and the obsession for detail his job demanded. Similarly, a young
woman's depression could be understood as neurasthenia brought on by the mental
drain of attending a newly founded coeducational university, where she competed
for grades. In many cases, diagnoses of neurasthenia attached themselves to
traditional ideals, such as the restorative virtues of farming vis-à-vis
the fast-paced stress of modern business or the Victorian belief in women's
disposition for motherhood rather than scholarship.2 For
Beard and Mitchell, neurasthenic patients were casualties of modern society
whose bodies and minds simply could not keep up with the seemingly accelerated
lifestyles of men and women in the latter part of the 19th century.

Medical treatment focused on mitigating the stressful impact of modernity
on people's lives. Mitchell's "rest cure," reserved mainly for women, became
the most famous of the therapies. Designed to increase the body's supply of
"fat and blood" that was thought necessary to generate nervous energy, the
rest cure kept patients in bed and on a diet of fatty foods for 6 to 8 weeks.
Massages were used to minimize muscle atrophy while the attending physician
counseled women on how to improve their health by embracing more domestic
lifestyles.7 But not all therapy was restful.
Physicians commonly sent afflicted men and their wives on rigorous "camp cures"8 amidst bucolic forests or on western ranches9 under the premise that eating roasted meat, breathing
fresh air, and living close to nature would replenish nervous energy. Neurasthenic
patients who could not afford surgery or the gamut of rest and camp cures
could seek temporary relief through minor electrical shock treatments (usually
performed in the physician's office) or patent medicines. Doctors also encouraged
proactive measures such as eating more fresh vegetables, exercising regularly,
taking vacations, and staying away from excess drinking and sexual activity.2

By the turn of the 20th century, neurasthenia had become a medical phenomenon
on both sides of the Atlantic and neurologists found themselves sharing authority
over the illness. Homeopaths, eclectics, general practitioners, and gynecologists
in Europe and America tried their hand at treating the condition, each putting
their discipline's own spin on the illness.10 Well-known
personalities such as philosopher William James, sociologist Max Weber, social
reformer Jane Addams, and feminist Charlotte Perkins Gilman experienced the
illness and helped define neurasthenia in the public mind. Incorporating neurasthenic
characters into fiction also became vogue, with Edith Wharton, Theodore Dreiser,
Henry James, Thomas Mann, and André Gide—many of whom were neurasthenic
themselves—all exerting a powerful influence over the popular understanding
of the illness.11 Adding to this hodgepodge
of influences, the Christian Science2 and
Emmanuel movements12 gave the diagnosis
a spiritualist edge by claiming to be able to heal the illness through religious
faith. Encouraged by medical professionals, modeled by the social elite, contained
within the pages of popular fiction, and showcased by religion, the disease
became broadly defined by physicians and the general public alike. It also
became ubiquitous, with one physician in 1906 likening neurasthenia to a "household
word."13

Neurasthenia's expansion into public discussion sometimes took the form
of reform movements that questioned the conservative cultural values Beard
and Mitchell wove into their initial diagnoses. Jane Addams and Charlotte
Perkins Gilman provide good examples of this. As part of a women's movement
that became increasingly influential as the 19th century came to an end, Addams
and Gilman challenged the strict gender roles advocated by Beard and Mitchell.
Through speeches and her best-selling account of the settlement house movement,
Addams urged the growing ranks of young college women to avoid neurasthenia
by dedicating themselves to helping the urban poor. Social work, she argued,
would allow them to escape the neurasthenia-inducing doldrums awaiting those
who followed Victorian expectations and sequestered themselves within the
home.14,15 Gilman believed
American housewives followed out-of-date and inefficient work schedules that
caused a needless waste of nervous energy. She suggested improving the situation
by embracing modernity, redefining women's work, and managing housework along
the most up-to-date business models so that women would have the same economic
freedoms as men.16,17 In
effect, within 30 years of neurasthenia's debut as a diagnosis, Addams and
Gilman sought to reverse Beard and Mitchell's conservative cultural message
by reframing traditional sensibilities (eg, rigid Victorian gender roles)
as the cause of poor health, not the cure.

As Addams, Gilman, and their contemporaries redefined neurasthenia according
to their personal sensibilities, the diagnosis grew unwieldy, lost much of
its practical use, and found itself in need of further refinement. Physicians
and the general public began to offer diagnoses for more narrowly defined
ailments. For instance, if symptoms targeted the heart and chest, De Costa
syndrome might be diagnosed.18 Soldiers
during World War I came down with "shell shock," "soldier's heart," and "effort
syndrome"—all neurasthenia-esque conditions that had no obvious organic
cause but needed to be distinguished from the general neurasthenia commonly
associated with overworked businessmen and educated women.19 As
early as 1904, neurologist Charles Dana argued that the condition had become
too broadly defined and should be phased out in favor of more specific diagnoses
adopted from psychiatry.20 Sigmund Freud
helped to fuel this psychosomatic shift with his Clark University lectures
in 1909.2

Cases of neurasthenia reached a peak near the turn of the 20th century,
and by the 1930s fewer and fewer physicians were diagnosing the disease.2 There are a number of explanations for this decline,
including modern medicine's abandonment of the "nervous energy" model of health
and the rise of Freud's psychoanalysis as a way of explaining and treating
psychosomatic disorders. Equally important seems to be neurasthenia's heavy
reliance on cultural explanations; developments seen as dramatic and potentially
unhealthy a half century before—such as urbanization, the growth of
office work, and women's increased participation in society—became more
commonplace and were less frequently thought of as unhealthy. Ultimately,
neurasthenia fell victim to its own widespread popularity as a cultural phenomenon
that made it overly broad and no longer useful to a medical profession increasingly
concerned with narrow diagnoses.